Practice Guideline

. 2025 Mar 1;53(3):e711-e727.

doi: 10.1097/CCM.0000000000006574. Epub 2025 Feb 21.

A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

Kimberley Lewis^{1

2

3}, Michele C Balas⁴, Joanna L Stollings^{5

6}, Molly McNett⁷, Timothy D Girard⁸, Gerald Chanques⁹, Michelle E Kho^{3

10

11}, Pratik P Pandharipande^{6

12}, Gerald L Weinhouse¹³, Nathan E Brummel¹⁴, Linda L Chlan¹⁵, Makayla Cordoza^{6

16

17}, Jeremiah J Duby¹⁸, Céline Gélinas^{19

20}, Erin L Hall-Melnychuk^{21

22}, Anna Krupp²³, Patricia R Louzon²⁴, Judith A Tate⁷, Bethany Young²⁵, Ron Jennings¹, Anitra Hines¹, Chris Ross¹, Kallirroi Laiya Carayannopoulos^{1

2

3}, J Matthew Aldrich²⁶

Affiliations

¹ Department of Medicine, McMaster University, Hamilton, ON, Canada.
² Department of Health Research, Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
³ Research Institute of St Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
⁴ University of Nebraska Medical Center, College of Nursing, Omaha, NE.
⁵ Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN.
⁶ Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, TN.
⁷ College of Nursing, The Ohio State University, Columbus, OH.
⁸ Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
⁹ Department of Anesthesia & Critical Care Medicine, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France.
¹⁰ School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada.
¹¹ Physiotherapy Department, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
¹² Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
¹³ Department of Medicine, Brigham and Women's Hospital, Boston, MA.
¹⁴ Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH.
¹⁵ Division of Nursing Research, Department of Nursing, Mayo Clinic, Rochester, MN.
¹⁶ School of Nursing, Vanderbilt University, Nashville, TN.
¹⁷ Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
¹⁸ Department of Pharmacy Services, UC Davis Health (UCDH), Sacramento, CA.
¹⁹ Ingram School of Nursing, McGill University, Montreal, QC, Canada.
²⁰ Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada.
²¹ Departments of Trauma Surgery and Critical Care Medicine, Geisinger Medical Center, Danville, PA.
²² Department of Psychiatry, Geisinger Commonwealth School of Medicine, Scranton, PA.
²³ Acute and Critical Care Division, College of Nursing, University of Iowa, Iowa City, IA.
²⁴ Department of Pharmacy, AdventHealth Orlando, Orlando, FL.
²⁵ Department of Nursing, Hospital of the University of Pennsylvania, Philadelphia, PA.
²⁶ Anesthesia and Perioperative Care, Critical Care Medicine, University of California, San Francisco, San Francisco, CA.

PMID: 39982143
DOI: 10.1097/CCM.0000000000006574

Practice Guideline

A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

Kimberley Lewis et al. Crit Care Med. 2025.

. 2025 Mar 1;53(3):e711-e727.

doi: 10.1097/CCM.0000000000006574. Epub 2025 Feb 21.

Authors

Affiliations

¹ Department of Medicine, McMaster University, Hamilton, ON, Canada.
² Department of Health Research, Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
³ Research Institute of St Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
⁴ University of Nebraska Medical Center, College of Nursing, Omaha, NE.
⁵ Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN.
⁶ Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, TN.
⁷ College of Nursing, The Ohio State University, Columbus, OH.
⁸ Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
⁹ Department of Anesthesia & Critical Care Medicine, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France.
¹⁰ School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada.
¹¹ Physiotherapy Department, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
¹² Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
¹³ Department of Medicine, Brigham and Women's Hospital, Boston, MA.
¹⁴ Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH.
¹⁵ Division of Nursing Research, Department of Nursing, Mayo Clinic, Rochester, MN.
¹⁶ School of Nursing, Vanderbilt University, Nashville, TN.
¹⁷ Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
¹⁸ Department of Pharmacy Services, UC Davis Health (UCDH), Sacramento, CA.
¹⁹ Ingram School of Nursing, McGill University, Montreal, QC, Canada.
²⁰ Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada.
²¹ Departments of Trauma Surgery and Critical Care Medicine, Geisinger Medical Center, Danville, PA.
²² Department of Psychiatry, Geisinger Commonwealth School of Medicine, Scranton, PA.
²³ Acute and Critical Care Division, College of Nursing, University of Iowa, Iowa City, IA.
²⁴ Department of Pharmacy, AdventHealth Orlando, Orlando, FL.
²⁵ Department of Nursing, Hospital of the University of Pennsylvania, Philadelphia, PA.
²⁶ Anesthesia and Perioperative Care, Critical Care Medicine, University of California, San Francisco, San Francisco, CA.

PMID: 39982143
DOI: 10.1097/CCM.0000000000006574

Abstract

Rationale: Critically ill adults are at risk for a variety of distressing and consequential symptoms both during and after an ICU stay. Management of these symptoms can directly influence outcomes.

Objectives: The objective was to update and expand the Society of Critical Care Medicine's 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

Panel design: The interprofessional inclusive guidelines task force was composed of 24 individuals including nurses, physicians, pharmacists, physiotherapists, psychologists, and ICU survivors. The task force developed evidence-based recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Conflict-of-interest policies were strictly followed in all phases of the guidelines, including task force selection and voting.

Methods: The task force focused on five main content areas as they pertain to adult ICU patients: anxiety (new topic), agitation/sedation, delirium, immobility, and sleep disruption. Using the GRADE approach, we conducted a rigorous systematic review for each population, intervention, control, and outcome question to identify the best available evidence, statistically summarized the evidence, assessed the quality of evidence, and then performed the evidence-to-decision framework to formulate recommendations.

Results: The task force issued five statements related to the management of anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adults admitted to the ICU. In adult patients admitted to the ICU, the task force issued conditional recommendations to use dexmedetomidine over propofol for sedation, provide enhanced mobilization/rehabilitation over usual mobilization/rehabilitation, and administer melatonin. The task force was unable to issue recommendations on the administration of benzodiazepines to treat anxiety, and the use of antipsychotics to treat delirium.

Conclusions: The guidelines task force provided recommendations for pharmacologic management of agitation/sedation and sleep, and nonpharmacologic management of immobility in critically ill adults. These recommendations are intended for consideration along with the patient's clinical status.

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Conflict of interest statement

Dr. Lewis received research funding from the Canadian Institutes of Health Research (CIHR) for the use of dexmedetomidine during noninvasive ventilation. Drs. Balas and Girard received funding from Ceribell. Dr. Balas received research funding from the National Heart, Lung, and Blood Institute (NHLBI), the National Institute of Nursing Research (NINR), and the National Institute of Child Health and Development (NICHD) of the National Institute of Health under award numbers NHLBI/NINR 1 UG3 HL165740-01A1; NINR 1 R01 NR020707-01; and NICHD 1 R01 HD103811-01; she currently serves on the American Association of Critical Care Nurses (AACN) Healthy Work Environment Collaborative and the American Psychiatric Association’s Delirium Guideline Committee; and she received honorariums from Ceribell, the Society of Critical Care Medicine (SCCM), and the AACN. Drs. McNett and Girard received funding from the National Institutes of Health (NIH). Dr. McNett received funding from Dexcom and the Patient-Centered Outcomes Research Institute. Dr. Girard received funding from Liberate Medical, Lungpacer, and the Department of Defense. Dr. Kho received funding from Restorative Therapies, the Canada Foundation for Innovation, the Canada Research Chair in Critical Care Rehabilitation and Knowledge Translation, and the CIHR for a randomized trial of in-bed cycle ergometry; she received a loan of four RT300 supine cycle ergometers for her research from Restorative Therapies, Baltimore, MD. Dr. Weinhouse received funding from UpToDate. Dr. Chlan received research funding from the NHLBI (1R01 HL 130881-01), the National Eye Institute (NIH R01AG067631), and the National Institute on Aging of the NIH under award numbers 5R01 HL 130881; R01 AG067631; and 3R01AG067631-04S1; she currently serves as a member of the Observational Study Monitoring Board for the Acute Respiratory Distress Syndrome, Pneumonia, and Sepsis phenotyping Consortium. Dr. Gélinas received funding from the CIHR (funding numbers 168983 and 169043) for ICU pain projects; she is currently involved as Co-Chair of the Fourth Edition of the Best Practice Guideline Update on the Assessment and Management of Pain of the Registered Nurses’ Association of Ontario. Dr. Gélinas received funding from the SCCM and the SAMDOC Medical Technologies. Dr. Krupp has research funding from the NHLBI and the NINR under award number 1 UG3 HL165740-01A1 and the Agency for Healthcare Research and Quality under award number 1 R21 HS029959-01; she disclosed that she was an invited speaker for Fall 2022 American Association of Nurse Practitioners. Dr. Young received funding from the Southeastern Pennsylvania Chapter of American Association of Critical-Care Nurses. Dr. Cordoza received research funding from NINR of the NIH for the investigation of sleep and delirium. The remaining authors have disclosed that they do not have any potential conflicts of interest.

References

1. Elliott D, Davidson JE, Harvey MA, et al.: Exploring the scope of post–intensive care syndrome therapy and care. Crit Care Med 2014; 42:2518–2526
1. Needham DM, Davidson J, Cohen H, et al.: Improving long-term outcomes after discharge from intensive care unit. Crit Care Med 2012; 40:502–509
1. Saltnes-Lillegård C, Rustøen T, Beitland S, et al.: Self-reported symptoms experienced by intensive care unit patients: A prospective observational multicenter study. Intensive Care Med 2023; 49:1370–1382
1. Devlin JW, Skrobik Y, Gélinas C, et al.: Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 2018; 46:e825–e873
1. Barr J, Fraser G, Puntillo K, et al.: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41:263–306

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A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

Affiliations

A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

Authors

Affiliations

Abstract

Conflict of interest statement

References

Publication types

MeSH terms

Substances

LinkOut - more resources

Full Text Sources

Medical